During Lyn Votour’s struggle against bone cancer and a cascade of complications, her husband slept with her in the intensive care unit for nine weeks. Back home in Central Massachusetts, he changed her bandages, replaced her feeding tube, and shielded her from debt collectors.

And as she lay dying on the hospital bed in their living room, he snuggled beside her, holding her hand. They had been married 26 years, and his wife’s death at age 46 overpowered Gary Votour with doubt and rage. He was furious at himself for allowing her to have surgery, during which she had a stroke, at friends who didn’t visit, and at his wife’s neurosurgeon.

Believing that airing his concerns would help him heal, Votour requested a meeting with the surgeon at Brigham and Women’s Hospital. When the surgeon turned him down, Votour’s psychiatrist urged him to write her an “open letter’’ online, detailing his concerns about his wife’s medical care.

He got a response, just not the one he had hoped for. Last month, the surgeon, Dr. Sagun Tuli, sued Votour and the owner of the website for defamation in Middlesex Superior Court, demanding $100,000 for the damage she said the blog post had done to her career. Her lawyer, David Rich of Boston, said Votour’s blog popped up on the first page of Google search results for Tuli, who now works at Metro West Medical Center in Framingham. Votour has since removed the blog post. “It’s difficult to believe we have a legal system that allows people to be sued for expressing their grief,’’ Votour said in an interview.

Tuli’s lawsuit is part of a gathering wave of claims brought by doctors against former patients, and sometimes their relatives, over negative ratings and reviews they have posted on the Internet, lawyers say.

Not only have personal blogs proliferated, but consumer sites such as Yelp and Angie’s List allow patients to rate and comment on their physicians. These sites are viewed by thousands of people who increasingly rely on them to choose doctors.

David Ardia, Co-Director of the Center for Media Law and Policy at the University of North Carolina, said the Internet “has realigned the power structure that existed between doctors and patients,’’ giving patients far more influence than they have ever had. “The Web is just chock-full of people commenting on their experiences. Doctors have reacted with a great deal of hostility toward this.’’

A quick perusal of Yelp reveals the kind of comments that are riling doctors. “Fast, Central, Misguided,” said one comment about a Copley Square practice. “Decent for your quick fix med tricks but leaves a bit to be desired in taking the time to truly understand the ailment.” Wrote another commenter about a Fenway office: “I feel much more like a number than a human being there.”

The Digital Media Project at Harvard University tracks lawsuits filed against patients and others for online comments. Its website includes seven such cases filed over the past five years or so, though it’s not a comprehensive list. In some, patients took down their negative comments. In others, judges dismissed the suit, ruling that patients’ comments were protected under the First Amendment guarantee of free speech.

In one 2011 case, Dr. Aaron Filler, a neurosurgeon, sued a former patient in a Los Angeles court for posting negative comments about him on rating sites such as RateMDs.com, including that he posed an unusually high risk of death to patients. A judge dismissed Filler’s suit, deciding that the patient was exercising free speech on a public issue, and ordered the doctor to pay $50,000 in legal fees.

Doctors feel they are at a disadvantage in responding to negative reviews because medical privacy laws forbid them from discussing a patient’s care in public — a limitation that hotels, restaurants, and other often-rated businesses and professionals don’t face. They also worry that their explanations could be used against them in a malpractice suit — although a new Massachusetts law protects doctors’ apologies.

Dr. Richard Aghababian, president of the Massachusetts Medical Society, believes rating websites present a skewed picture of doctors because patients are more likely to post about negative experiences — even though they may be rare. “For surgeons, their reputation is very important,” he said. “We don’t want to discourage them from taking on really tough cases because they don’t want to ruin their ratings.’’

Companies have cropped up to help doctors fight back. Physicians Reputation Defender specializes in disputing negative online ratings. Medical Justice gathers reviews from a doctor’s patients and posts them on the Internet.

Ultimately, some doctors file lawsuits to try to protect their names, despite what Ardia calls “the reputational cost’’ of going to court, a step that often brings even more attention to the negative review.

While the rating sites are generally immune from libel claims, said Sandra Baron, executive director of the Media Law Resource Center in New York, individuals who post comments are not. In general for a doctor to win such a suit, she said, the statements made by the patient have to be shown to be false and to have hurt the doctor’s reputation.

Most lawsuits filed by doctors against patients or their families arise from a soured relationship, and that certainly seems true for the Votours and Tuli.

Lyn Votour was diagnosed with a rare bone cancer after an accident in 2005. In March 2005, Lyn Votour was driving to her job counseling troubled youth when her car skidded on black ice and crashed. An ambulance rushed her to a local hospital, and tests on her neck eventually discovered a rare bone cancer unrelated to the accident. An oncologist at Brigham referred her to Tuli to have some of her vertebrae removed, a complicated and rare operation. During a second surgery, Votour suffered a stroke that paralyzed the left side of her body.

The Votours and Tuli seemed to work well together at first. Tuli, for example, supported allowing Gary Votour to sleep in the ICU for an extended period, an unusual practice. But after Lyn Votour was discharged to Spaulding Rehabilitation Hospital, the couple’s relationship with Tuli deteriorated, according to Gary Votour. His wife was eventually discharged to the couple’s home in Barre in July 2006 with a feeding tube and a breathing tube.

More than two years later, depressed and in pain, she asked her husband to remove her feeding tube, he said. Soon she stopped talking, he wrote on the blog, except for “one brief lucid moment when she thanked me for letting her go and made me promise to move on with my life and try to find happiness again.’’ She died days later, in October 2008. “I was not doing well with grief,’’ he said in an interview. “I wanted to go back and talk to Dr. Tuli about some questions that were bothering me. I really wanted to ask her why don’t doctors follow up after discharge. I wanted to understand why doctors just wash their hands after discharge.’’

Votour contacted a patient advocate at the Brigham, who said she would arrange a meeting. But the advocate called back and said Tuli had declined to meet, Votour said. Rich, her attorney, said a Brigham lawyer told Tuli not to meet with Votour.

A hospital spokeswoman, Erin McDonough, said in a written statement that a log kept by the patient advocate “documents that Dr. Tuli indicated that she was not comfortable meeting with Mr. Votour. . . . The hospital’s records clearly indicate it was her decision.’’ The hospital lawyer said she never spoke to Tuli about Votour’s request, McDonough said.

Frustrated, Votour put up his blog in March 2010 and e-mailed a link to Tuli and other Brigham staff who had cared for his wife.In his post, Votour criticized Tuli for not visiting his wife at Spaulding, according to a copy of the blog included in the lawsuit. He wrote that the surgeon called their home once after her discharge but did not offer to help coordinate her care, and that Spaulding doctors and others urged him to file a lawsuit against Tuli. At another point, he said he lost his wife “not to cancer but to indifference and egotism.’’

In the lawsuit, Tuli said these statements are false and defamatory. In written comments, Rich said that patient privacy laws prevent Tuli from discussing the reasons for the stroke, but according to the blog, she told the Votours it was caused by a preexisting tear in the heart.

Rich wrote that Votour completely misunderstood how discharge planning works at large hospitals. Tuli, Rich said, did not have privileges to treat his wife at another hospital and they lived too far away for her to provide follow-up care.

Rich said Tuli was surprised by the blog, because Votour had previously written e-mails complimenting her care of his wife. After Lyn Votour’s stroke, Tuli “spent 12 hours with Votour and was completely responsive and sympathetic,’’ Rich said.

Tuli, who won a $1.6 million jury award against the Brigham and the chief of neurosurgery in 2009 for gender discrimination, left the hospital in 2011.

Rich called the lawsuit a last resort — lawyers for Tuli initially asked Gary Votour to take down his blog in 2010. Votour took down the blog in February. He said his client hopes to “work out some amicable solution.’’ But she wants Votour to sign an agreement not to write about her again — something he has refused to do.

People have expressed concern to Tuli about what they read on Votour’s blog, Rich said, and some have certainly been dissuaded from seeking her out as a surgeon. “If you are thinking of hiring someone or working with someone, the first thing you do is Google her name,’’ he said.

In the end, Ardia said, doctors will not find satisfaction through the courts, but by using the Internet to their advantage — encouraging happy patients to write online reviews and trying to address the concerns of those who are not. “The ultimate solution is engagement and realizing that not every patient is going to be happy.’’

Votour, who still owes $25,000 to credit card companies for expenses related to his wife’s care, has moved to Columbia, S.C., where he earned a master’s degree in hospital administration. He now works as a patient advocacy consultant. He named his company Fierce Advocacy.

During Lyn Votour’s struggle against bone cancer and a cascade of complications, her husband slept with her in the intensive care unit for nine weeks. Back home in Central Massachusetts, he changed her bandages, replaced her feeding tube, and shielded her from debt collectors.

And as she lay dying on the hospital bed in their living room, he snuggled beside her, holding her hand.

They had been married 26 years, and his wife’s death at age 46 overpowered Gary Votour with doubt and rage. He was furious at himself for allowing her to have surgery, during which she had a stroke, at friends who didn’t visit, and at his wife’s neurosurgeon.

Believing that airing his concerns would help him heal, Votour requested a meeting with the surgeon at Brigham and Women’s Hospital. When the surgeon turned him down, Votour’s psychiatrist urged him to write her an “open letter’’ online, detailing his concerns about his wife’s medical care.

He got a response, just not the one he had hoped for.

Last month, the surgeon, Dr. Sagun Tuli, sued Votour and the owner of the website for defamation in Middlesex Superior Court, demanding $100,000 for the damage she said the blog post had done to her career. Her lawyer, David Rich of Boston, said Votour’s blog popped up on the first page of Google search results for Tuli, who now works at MetroWest Medical Center in Framingham. Votour has since removed the blog post.

“It’s difficult to believe we have a legal system that allows people to be sued for expressing their grief,’’ Votour said in an interview.

Lyn Votour was diagnosed with a rare bone cancer after an accident in 2005.

Tuli’s lawsuit is part of a gathering wave of claims brought by doctors against former patients, and sometimes their relatives, over negative ratings and reviews they have posted on the Internet, lawyers say.

Not only have personal blogs proliferated, but consumer sites such as Yelp and Angie’s List allow patients to rate and comment on their physicians. These sites are viewed by thousands of people who increasingly rely on them to choose doctors.

David Ardia, codirector of the Center for Media Law and Policy at the University of North Carolina, said the Internet “has realigned the power structure that existed between doctors and patients,’’ giving patients far more influence than they have ever had. “The Web is just chock-full of people commenting on their experiences. Doctors have reacted with a great deal of hostility toward this.’’

A quick perusal of Yelp reveals the kind of comments that are riling doctors. “Fast, Central, Misguided,” said one comment about a Copley Square practice. “Decent for your quick fix med tricks but leaves a bit to be desired in taking the time to truly understand the ailment.”

Wrote another commenter about a Fenway office: “I feel much more like a number than a human being there.”

The Digital Media Project at Harvard University tracks lawsuits filed against patients and others for online comments. Its website includes seven such cases filed over the past five years or so, though it’s not a comprehensive list. In some, patients took down their negative comments. In others, judges dismissed the suit, ruling that patients’ comments were protected under the First Amendment guarantee of free speech.

In one 2011 case, Dr. Aaron Filler, a neurosurgeon, sued a former patient in a Los Angeles court for posting negative comments about him on rating sites such as RateMDs.com, including that he posed an unusually high risk of death to patients. A judge dismissed Filler’s suit, deciding that the patient was exercising free speech on a public issue, and ordered the doctor to pay $50,000 in legal fees.

Doctors feel they are at a disadvantage in responding to negative reviews because medical privacy laws forbid them from discussing a patient’s care in public — a limitation that hotels, restaurants, and other often-rated businesses and professionals don’t face. They also worry that their explanations could be used against them in a malpractice suit — although a new Massachusetts law protects doctors’ apologies.

Dr. Richard Aghababian, president of the Massachusetts Medical Society, believes rating websites present a skewed picture of doctors because patients are more likely to post about negative experiences — even though they may be rare. “For surgeons, their reputation is very important,” he said. “We don’t want to discourage them from taking on really tough cases because they don’t want to ruin their ratings.’’

Companies have cropped up to help doctors fight back. Physicians Reputation Defender specializes in disputing negative online ratings. Medical Justice gathers reviews from a doctor’s patients and posts them on the Internet.

Ultimately, some doctors file lawsuits to try to protect their names, despite what Ardia calls “the reputational cost’’ of going to court, a step that often brings even more attention to the negative review.

While the rating sites are generally immune from libel claims, said Sandra Baron, executive director of the Media Law Resource Center in New York, individuals who post comments are not. In general for a doctor to win such a suit, she said, the statements made by the patient have to be shown to be false and to have hurt the doctor’s reputation.

Most lawsuits filed by doctors against patients or their families arise from a soured relationship, and that certainly seems true for the Votours and Tuli.

In March 2005, Lyn Votour was driving to her job counseling troubled youth when her car skidded on black ice and crashed. An ambulance rushed her to a local hospital, and tests on her neck eventually discovered a rare bone cancer unrelated to the accident.

An oncologist at Brigham referred her to Tuli to have some of her vertebrae removed, a complicated and rare operation. During a second surgery, Votour suffered a stroke that paralyzed the left side of her body.

The Votours and Tuli seemed to work well together at first. Tuli, for example, supported allowing Gary Votour to sleep in the ICU for an extended period, an unusual practice.

But after Lyn Votour was discharged to Spaulding Rehabilitation Hospital, the couple’s relationship with Tuli deteriorated, according to Gary Votour. His wife was eventually discharged to the couple’s home in Barre in July 2006 with a feeding tube and a breathing tube.

More than two years later, depressed and in pain, she asked her husband to remove her feeding tube, he said. Soon she stopped talking, he wrote on the blog, except for “one brief lucid moment when she thanked me for letting her go and made me promise to move on with my life and try to find happiness again.’’ She died days later, in October 2008.

“I was not doing well with grief,’’ he said in an interview. “I wanted to go back and talk to Dr. Tuli about some questions that were bothering me. I really wanted to ask her why don’t doctors follow up after discharge. I wanted to understand why doctors just wash their hands after discharge.’’

Votour contacted a patient advocate at the Brigham, who said she would arrange a meeting. But the advocate called back and said Tuli had declined to meet, Votour said.

Rich, her attorney, said a Brigham lawyer told Tuli not to meet with Votour.

A hospital spokeswoman, Erin McDonough, said in a written statement that a log kept by the patient advocate “documents that Dr. Tuli indicated that she was not comfortable meeting with Mr. Votour. The hospital’s records clearly indicate it was her decision.’’ The hospital lawyer said she never spoke to Tuli about Votour’s request, McDonough said.

Frustrated, Votour put up his blog in March 2010 and e-mailed a link to Tuli and other Brigham staff who had cared for his wife.

In his post, Votour criticized Tuli for not visiting his wife at Spaulding, according to a copy of the blog included in the lawsuit. He wrote that the surgeon called their home once after her discharge but did not offer to help coordinate her care, and that Spaulding doctors and others urged him to file a lawsuit against Tuli. At another point, he said he lost his wife “not to cancer but to indifference and egotism.’’

In the lawsuit, Tuli said these statements are false and defamatory. In written comments, Rich said that patient privacy laws prevent Tuli from discussing the reasons for the stroke, but according to the blog, she told the Votours it was caused by a preexisting tear in the heart.

Rich wrote that Votour completely misunderstood how discharge planning works at large hospitals. Tuli, Rich said, did not have privileges to treat his wife at another hospital and they lived too far away for her to provide follow-up care.

Rich said Tuli was surprised by the blog, because Votour had previously written e-mails complimenting her care of his wife. After Lyn Votour’s stroke, Tuli “spent 12 hours with Votour and was completely responsive and sympathetic,’’ Rich said.

Tuli, who won a $1.6 million jury award against the Brigham and the chief of neurosurgery in 2009 for gender discrimination, left the hospital in 2011.

Rich called the lawsuit a last resort — lawyers for Tuli initially asked Gary Votour to take down his blog in 2010. Votour took down the blog in February. He said his client hopes to “work out some amicable solution.’’ But she wants Votour to sign an agreement not to write about her again — something he has refused to do.

People have expressed concern to Tuli about what they read on Votour’s blog, Rich said, and some have certainly been dissuaded from seeking her out as a surgeon. “If you are thinking of hiring someone or working with someone, the first thing you do is Google her name,’’ he said.

In the end, Ardia said, doctors will not find satisfaction through the courts, but by using the Internet to their advantage — encouraging happy patients to write online reviews and trying to address the concerns of those who are not. “The ultimate solution is engagement and realizing that not every patient is going to be happy.’’

Votour, who still owes $25,000 to credit card companies for expenses related to his wife’s care, has moved to Columbia, S.C., where he earned a master’s degree in hospital administration. He now works as a patient advocacy consultant. He named his company Fierce Advocacy.

Tuli filed a $100,000 defamation lawsuit against him in Middlesex Superior Court in February.

Given the fervent reader interest in Votour’s situation, I want to provide an update on the case, as well as on another lawsuit I mentioned in my April story. It was brought by California neurosurgeon Dr. Aaron Filler against a former patient in 2011.

Most notably, Votour—who owes thousands of dollars in credit card debt for expenses related to Lyn’s illness—was taken under the wing of major Boston lawfirm Wilmer Hale, which agreed to represent him free of charge. The case was moved to federal court in Boston and Votour’s attorney, Adam Hornstine, has filed a motion to dismiss Tuli’s lawsuit.

The firm believes the case may have broader implications: Among other reasons, Hornstine has filed a potential challenge with the court and Attorney General Martha Coakley’s office to a state law that can hold people liable for making true statements under certain circumstances, which he argues is unconstitutional.

“It’s an affirmative defense protecting my right to free speech,’’ said Votour, who said he posted the blog because Tuli refused to meet with him to answer questions about a stroke his wife suffered during surgery.

While Votour took down his blog in February, he said settlement talks with Tuli have failed so far.

Tuli’s attorney, David Rich, said he could not comment on the case. But he told me last Spring that Votour’s criticisms were false and that the blog damaged his client’s career.

Her lawsuit is part of a wave of claims brought by doctors against former patients, and sometimes their relatives, over negative ratings and reviews they have posted on the Internet. These reviews have shifted the balance of power among doctors and patients. And while some lawyers say doctors only draw more attention to negative comments by suing over them, Filler said sometimes a physician needs to take strong action.

He sued a former patient in a Los Angeles court for posting negative comments about him on rating sites such as RateMDs.com, including “stating falsely that information she has seen suggested Dr. Filler posed an unusually high risk of death to patients,’’ according to his complaint.

Dr. Filler says he brought the case in part because none of his patients had died. While a judge dismissed Filler’s original suit, he said in a recent interview that he was able to get the patient, Susan Walker, to remove her comments and that additional litigation is pending. (In fact, the comment about risk of death was posted again by the patient from another site.) The comments “caused huge harm because there are hundreds of people suffering in pain right now’’ because they are too afraid to seek care from him, he said.

“My message is that physicians should respond to these things,’’ he said. “I don’t think you should be falsely accused of murder and take it. It was shouting fire in a crowded theater.’’

Walker’s attorney did not immediately respond to a request for comment.

“Physicians face barriers when fighting derogatory comments posted on the Internet, but some legal strategies can curb the problem”

Alicia Gallegos, AMedNews

“Horrible results!”

“The doctor misdiagnosed the case.”

“It was a failed surgery.”

When unhappy patients post these kinds of comments about physicians online, doctors’ reputations — and their practices — can suffer.

Reviews by patients have become common as blogs and review websites proliferate on the Internet. But doctors are seeking legal remedies to battle alleged online libel and defamation.

An Illinois plastic surgeon on Nov. 3 sued Google in federal court for failing to remove blog posts the doctor claims are libelous and false.

On Nov. 10, the Minnesota Court of Appeals heard arguments in the case of a neurologist suing a former patient’s family for alleged defamation. David McKee, MD, alleges that a family member made derogatory and untrue posts about his treatment of the man’s father. A ruling is expected by January 2012.

From 2009 to 2011, Chicago plastic surgeon Jay Pensler, MD, sued three patients and an attorney for alleged defamation stemming from comments left on review websites and for statements made to a TV station. One of the cases was settled, and three are ongoing, said an attorney involved in the litigation.

Taking legal action against Internet posters is not always ideal, legal experts say. However, doctors who do so should be aware of how best to navigate the judicial process.

Before suing, experts say doctors should consider all legal strategies that may help remove comments from a website. Knowing the right legal step to take — and when to take it — could be the difference between a quick remedy and a years-long ordeal.

“Lawsuits are time-consuming and they’re expensive, and they may not result in the outcome the physician wants,” said neurologist Daniel Larriviere, MD, a former medical liability attorney and current chair of the American Academy of Neurology’s Ethics, Law and Humanities Committee. But because of federal laws, “a physician can’t go onto the website where a comment is posted and defend themselves. For better or for worse, sometimes the only way for the physician to present his or her side of the story is to do so in court.”

Opinion vs. defamation

Before claiming defamation, physicians should understand its meaning. Though gray areas exist, defamation generally is a statement that can be proven true or false, said Enrico Schaefer, an Internet defamation and copyright attorney who founded the law firm Traverse Legal PLC in California.

For instance, an online poster who writes that he is a patient of a doctor and had a procedure performed has written a statement that usually can be confirmed or disproved, he said. On the other hand, a comment about being treated rudely while visiting a doctor is more of an opinion.

“While doctors have to have a thick skin about a patient’s opinion, we get a lot of calls where physicians are dealing with a posting where the [writer] is not a patient, where the person is unstable or has confused them with someone else, or where the poster is really” the doctor’s competition, he said.

In Dr. McKee’s case, a trial court ruled that the comments posted by Dennis Laurion, the son of one of Dr. McKee’s former patients, were not defamation but rather an “emotional discussion of the issues.” Dr. McKee appealed. He accused Laurion of writing untrue posts about his interaction with Laurion’s family, including a charge that the doctor did not treat his father with dignity after a stroke.

Laurion’s assertions go beyond opinion, said Marshall H. Tanick, Dr. McKee’s attorney. “He felt he was viciously defamed by the son of a patient. He sued to vindicate his reputation,” Tanick said. “We maintain these statements cross the line. [They are] demonstrably false.”

Laurion’s attorney, John D. Kelly, said some of Laurion’s statements were true and the rest were vague or obvious opinions. For example, Laurion wrote that Dr. McKee was “scowling” during his interaction with Laurion’s family, Kelly said. Statements about a person’s expression or demeanor are open to interpretation and cannot be considered defamatory, he said. If doctors aren’t sure if an online comment is defamatory, seeking legal guidance can help, Schaefer said.

People behind the posts

Anonymous posts create challenges for doctors who want to remove negative blogs. However, identifying people behind posts is sometimes as simple as asking. Most websites have policies against libelous statements, Schaefer said.

Questioning website operators about false posts could lead to removal or to finding out posters’ identities. If that doesn’t work, physicians can seek a subpoena ordering the Internet service provider to give identification data, said Sheldon Halpern, a professor at the Albany Law School in New York. “Generally, whether you’re a doctor or anyone else and someone has posted what is really defamatory statements about you, you can get a court to require the ISP to give you the name of the person who did it,” he said.

Doctors can contact the patient directly to ask that the post be removed or request that an attorney send a letter warning the poster of potential legal action, said Mitchell Marinello, an Illinois attorney who practices defamation law.

In one case, an investigation revealed that a blogger was posting negative comments from his employer’s email system. Once Marinello contacted the poster, he quickly removed the posts before making waves with his employer. “There is a whole series of things you can do short of a lawsuit, assuming that you’re dealing with a reasonable person,” Marinello said.

If requests to take down posts fail, seeking a court order is another option. If doctors can show that false posts are causing irreparable harm to their reputation or practice, a judge can demand the comments be removed.

That’s what Indiana plastic surgeon Barry Eppley, MD, sought in 2009 after finding Internet postings by Lucille Iacovelli, a patient who was unhappy about a facelift done by Dr. Eppley, court documents show. She also created Web pages about her experience. Dr. Eppley sued Iacovelli for defamation and other things. A federal judge granted a preliminary injunction against Iacovelli, preventing her or anyone “acting as her agent” from posting online comments about Dr. Eppley, according to court documents. She was ordered to remove prior postings about the doctor from her websites. A Web operator who did not remove postings about the doctor was ordered to pay Dr. Eppley $1,772. The operator is appealing. Dr. Eppley got $40,000 in damages and attorney fees.

“The record before the court demonstrates that Ms. Iacovelli has made numerous false and offensive statements about Dr. Eppley on public websites,” said Judge Sarah Evans Barker, U.S. District Court, Southern District of Indiana, in her ruling on the injunction. “As Indiana courts have held, when the speech enjoined is of lesser constitutional value because it is false and defamatory, and the injunction operates to address specifically that speech, the injunction passes constitutional muster under the First Amendment.”

To sue or not to sue?

Suing over negative posts is typically a last resort, Schaefer said. But lawsuits bring challenges. Legal proceedings often run for years and can draw more negative online attention for plaintiffs, he said. Schaefer said most states have a statute of limitations in which to file defamation suits. If negative online content is found years after being posted, physicians have no legal recourse. “There are no great answers here. You have to spend some time and some money to get the problem handled, and there are some instances where you’re stuck,” he said.

If doctors sue, experts say individual posters, not websites, are the more logical defendants. The Communications Decency Act of 1996 protects Internet service providers from liability for third-party comments.

Some physicians, such as New Hampshire internist Kevin Pho, MD, believe legal action is the wrong answer to curb negative Internet reviews and blogs. “In general, I can’t think of a time where a lawsuit would be tremendously effective. The negative publicity and the fallout from the lawsuit is far worse than the initial issue,” said Dr. Pho, who writes a physician-focused blog on health and social media called KevinMD.com. “It’s a better idea to take charge of your online presence.” For instance, doctors should have a Facebook page, join other social networking sites and participate in blogs, he said. Those links show up first during a Google search of a physician’s name, pushing negative reviews farther down.

Physicians also should consider distributing satisfaction surveys to their patients, said Susan Shepard, RN, director of patient safety education and electronic issues for The Doctors Company, a medical liability insurer. Surveys provide a forum for patients to express their feelings about visits and allow doctors instant feedback about problems that may need to be addressed. “I would encourage practices to look at a visit through the patient’s eyes — look at the comfort standards. There’s a lot more to a physician visit than having the current magazines in the waiting room,” she said. Shepard discourages doctors from taking legal action against online blogs or review sites. “I understand the anger and the need to get back at someone, but it’s very difficult to sue someone for an opinion,” she said. “Most of the comments are very subjective, meaning neither one can prove the other is wrong.”

If a professional reputation is to be protected at all costs, should a healthcare provider file a lawsuit against a patient for a negative online review?

From time to time we see news items about doctors or dentists who threaten legal action against patients. But suing a patient for a negative comment (or comments) is likely to be a bad idea. In fact, it just might be the worst thing to do.

We can sympathize with a practitioner’s frustration and outright anger. Negative comments and online reviews can be untrue, unkind and one sided. What’s more, we’ve never met a doctor, dentist, physician, surgeon or other healthcare provider who isn’t fiercely protective of his or her personal and professional reputation.

Their reputation—real or perceived, in person or online—is the sum of everything they do. And from a physician marketing perspective, their personal and practice reputation is at the heart of their brand and branding message. It’s no wonder that healthcare providers—doctors in particular—are highly sensitive and sometimes nearly fanatical about any and all reflections on their reputation.

We’re not offering legal advice here, but we discussed the concept of online comments with our friend and noted healthcare attorney Stephen Kaufman. He told us, “Sometimes I can convince the website to pull the [offending] comment. Sometimes, we write a reply. But I have never sued, and I’m hard-pressed to imagine a circumstance where I would recommend doing so.”

And while a lawsuit may “feel” justified, there are good reasons to reconsider the temptation for a dentist or physician to “strike back” in court. From a healthcare public relations and marketing perspective.

The “doctor-sues-patient” story is likely to grab much more media attention than the original patient review. A small local story can suddenly go national. It’s the PR equivalent to throwing gasoline on embers. It’s going to ignite a flash fire with an explosive downside and not much of an upside.

The general public is likely to identify with–and sympathize with–the patient, not the doctor. Other doctors might quietly commiserate a little, but in the larger “court of public opinion” the doctor may be seen as the villain for starting a fight.

The Internet Search Engines will also take notice. Any ensuing controversy about the lawsuit will itself capture high page rankings and will continue to appear in Google search results—and overshadow any positive marketing efforts—perhaps for years.

And then there are the legal costs, the prospect of counter claims and the drain on personal and professional time and resources.

Our comments here do not refer to the merits of any specific situation, and it’s always a good idea to seek professional legal counsel regarding your situation. Physician-rating websites and online reviews and commentary provide patients with a channel to publish their feelings—good, bad or otherwise—about physician performance.

A study published in the Journal of General Internal Medicine found the majority of such reviews (88%) to be positive, six percent were neutral and six percent were negative.

In our experience, the concept of a healthcare provider suing a patient for an “unfriendly” review should be approached with considerable care. It’s likely to be a “legally dumb” healthcare marketing and PR move.

Stewart Gandolf is CEO of Healthcare Success Strategies, a medical marketing and health care advertising agency. He is also a frequent writer and speaker.

Since its founding in 2005, Yelp.com—a website where consumers review everything from cappuccinos to car mechanics—has published more than 5 million write-ups of local merchants. But in the past twelve months its online reviews have also triggered at least three defamation lawsuits.

Positive reviews can attract new customers—but negative reviews may inspire the subjects to head to court. One suit, waged by a chiropractor who was poorly reviewed on Yelp, settled in mediation earlier this year, and a second suit, filed last year by a pediatric dentist, is pending on appeal. A third case, also involving a dentist, settled last year after a superior court judge in San Francisco, where Yelp is based, granted the defendant’s anti-SLAPP (Strategic Lawsuits Against Public Participation) motion. California attorneys, meanwhile, say they’re fielding an increasing number of calls from angry business owners seeking recourse.

“It shouldn’t come as a surprise, due to the sheer increase in popularity of these sites in the past year,” says Matt Zimmerman, a senior staff attorney at the Electronic Frontier Foundation, a nonprofit civil liberties law firm in San Francisco that specializes in high-tech legal issues.

Suing the host sites for their user-generated content is, of course, fruitless: Section 230 of the federal Communications Decency Act (CDA) shields the sites from defamation suits as long as they didn’t create the objectionable materials.

The aggrieved parties, however, can and do go after the reviewers (known as posters) who publish their opinions online. Legally, posters have plenty of leeway – as long as they don’t cross the line into defamation, says Karl Kronenberger, a partner at San Francisco’s Kronenberger Burgoyne who represents businesses in such matters. And California’s anti-SLAPP law shields people who speak out on issues of public interest—a protection that broadly extends to consumer matters.

In addition to being difficult to prove and win, allegations of online defamation can also backfire: A stray negative posting may fade into obscurity, but a lawsuit over it can provoke exactly the kind of negative publicity that business owners are desperate to avoid, notes Mark Lemley, who teaches Internet law at Stanford Law School and is a partner at Durie Tangri Lemley Roberts & Kent in San Francisco.

This is a key reason many experts advise that, whenever possible, attorneys should help their clients settle such matters. In fact, Yelp is among the sites that try to mediate between merchants and consumers by hooking them up to smooth out their differences. And in April, Yelp followed sites such as Trip Advisor and eBay by letting merchants respond online to negative feedback.

In the meantime, the smartest strategy for merchants who’ve suffered a withering critique may be to rally patrons to post rave reviews. “The answer to negative speech, especially online, isn’t to try to silence people,” Zimmerman says, “but to encourage more speech.”

Gary Votour’s wife, Lyn, died of complications from bone cancer and soon after, he blogged about his dissatisfaction with the medical care Dr. Sagun Tuli had given her. Dr. Tuli filed a $100,000 defamation lawsuit against him in Middlesex Superior Court in February.

Votour – who owes thousands of dollars in credit card debt for expenses related to Lyn’s illness – was taken under the wing of major Boston lawfirm, WilmerHale, which agreed to represent him free of charge.

The case was moved to federal court in Boston and Votour’s attorney, Adam Hornstine, has filed a motion to dismiss Tuli’s lawsuit. The firm believes the case may have broader implications: Among other reasons, Hornstine has filed a potential challenge with the court and Attorney General Martha Coakley’s office to a state law that can hold people liable for making true statements under certain circumstances, which he argues is unconstitutional. “It’s an affirmative defense protecting my right to free speech,’’ said Votour, who said he posted the blog because Tuli refused to meet with him to answer questions about a stroke his wife suffered during surgery.

While Votour took down his blog in February, he said settlement talks with Tuli have failed so far.

Tuli’s attorney, David Rich, said he could not comment on the case. But he told me last Spring that Votour’s criticisms were false and that the blog damaged his client’s career.

This lawsuit is part of a wave of claims brought by doctors against former patients, and sometimes their relatives, over negative ratings and reviews they have posted on the Internet. These reviews have shifted the balance of power among doctors and patients.